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Peripheral Nerve Injuries of the Upper Limb Stacy Rudnicki, MD Associate Professor of Neurology.

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Presentation on theme: "Peripheral Nerve Injuries of the Upper Limb Stacy Rudnicki, MD Associate Professor of Neurology."— Presentation transcript:

1 Peripheral Nerve Injuries of the Upper Limb Stacy Rudnicki, MD Associate Professor of Neurology

2 Aids to the Examination of the Peripheral Nervous System –WB Saunders, publishers

3 Definitions

4 Radiculopathy Process affecting the nerve root, most commonly by a herniated disc –Weakness in muscles supplied by the nerve root (myotome) –Sensory loss in the area of the skin supplied by the nerve root (dermatome)

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6 Mononeuropathy Dysfunction of a single peripheral nerve –Weakness in muscles supplied by the nerve –Sensory loss in the area of the skin supplied by the cutaneous branches of the nerve

7 Brachial Plexopathy Can refer to involvement of the entire plexus, or parts of the plexus –Trunk lesion –Cord lesion Distribution of weakness and numbness depends upon the part of the plexus affected

8 Sensory Supply to the Arm Because fibers from different nerve roots come together and then split apart in the plexus –A dermatome may include areas of the skin supplied by different peripheral nerves Example: C6 –A single nerve may supply sensation to skin covered by more than one dermatome Example: median nerve

9 Sensory Supply to the Arm Because of the pattern of root contribution to the plexus: –An upper trunk lesion has sensory loss in the combined C5,6 dermatomes –A middle trunk lesion has sensory loss in the C7 dermatome –A lower trunk lesion has sensory loss in the combined C8T1 dermatomes

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11 Principles of Localization Certain sites are prone to nerve entrapments/injuries –Nerve opposing bone Ulnar nerve at the elbow –Closed spaces Carpal tunnel –Adjacent structures Median nerve at the elbow, adjacent to the brachial artery

12 Principles of localization, cont Order in which branches arise Movements at specific joints –Single nerve Elbow extension –Radial –Multiple nerves Elbow flexion –Musculocutaneous –Radial Thumb –Multiple different movement accomplished by multiple muscles innervated by the median, ulnar, and radial nerves

13 Additional Helpful Hints All muscles within the hand (intrinsic hand muscles) –Are innervated by C8T1 nerve roots –Are innervated by the lower trunk –Are innervated by the medial cord All ulnar innervated muscles –Are innervated by the C8T1 nerve roots –Are innervated by the lower trunk –Are innervated by the medial cord All axillary and musculocutanious innervated muscles –Are innervated by C5,6 nerve roots –Are innervated by the upper trunk

14 Additional Helpful Hints, cont Muscles inserting onto the humerus (and so related to movements of the arm) are primarily C5,6 –Infraspinatus –Supraspinatus –Deltoid –Teres minor –Teres major (Plus C7) –Pectoralis Major (plus C7) Latissimus is C6,7,8

15 Work Back from the Exam What muscles are weak? What innervates the muscle? –Peripheral nerve –Part of plexus Cord Trunk –Nerve roots Where is the sensory loss? Does it best follow the pattern of –A dermatome –A single nerve –A cord or trunk of the plexus

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17 Case 1 A 34 yo woman, currently 28 weeks pregnant, complains of numbness in her fingers She finds that it is more difficult to manipulate small objects She is awakened at night be tingling and pain in her hand which seems to spare her little finger

18 Case 1, continued On exam she has: –Mild weakness of thumb abduction and opposition –Decreased pin prick on the palmar aspect of the thumb, index, middle and lateral aspect of the ring finger –No evidence of loss of muscle bulk in the hand

19 Case 1, continued FindingMuscle NervePlexusRoot Thumb Abd APBMedian Lower trunkC8T1 Medial cord Thumb oppOPMedianLower trunkC8T1 Medial cord Sensory lossMedian------

20 FindingMuscle NervePlexusRoot Thumb Abd APBMedian Lower trunkC8T1 Medial cord Thumb oppOPMedianLower trunkC8T1 Medial cord Sensory loss-----Median------

21 Why isn’t this the medial cord, lower trunk, or C8T1 nerve roots?

22 All should also involve ulnar innervated muscles

23 Why aren’t the other median innervated muscles involved?

24 Median Nerve

25 Case 1, continued Final Diagnosis Carpal tunnel syndrome (median neuropathy at the wrist)

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27 Case 2 A 38 yo woman was the restrained passenger in a car struck head on She braced her hands on the dashboard immediately prior to impact She suffered bilateral fractures of the humerus at the spiral (radial) groove She complains of diffuse aches in her arms and neck and weakness in her arms

28 Case 2, cont On exam she has: –Bilateral wrist and finger drop (ie profound weakness of wrist and finger extension at the MCPs) –Weakness of thumb extension – Weakness of supination –Weakness of elbow flexion with forearm held so that thumb is toward shoulder, but not with hand held in supination –Remainder of strength exam is normal

29 Sensory Loss

30 Case 2, cont FindingMusclePNPlexus*Root Wr dropECR, ECURadialPOST C C5,6,7,8 Fing dropEDC,EIRadial POST C C7, C8 Elb flxBRRadialPOST C C5,C6 Th ExtEPL, EPBRadialPost CC7,8 Sens ----Radial------

31 FindingMusclePNPlexus*Root Wr drop ECR, ECURadialPOST C C5,6,7,8 Fing drop EDC,EIRadial POST C C7, C8 Elb flx BRRadialPOST C C5,C6 Sens ----Radial------

32 What isn’t involved? If it is a Posterior Cord lesion –Axillary nerve Deltoid – arm abduction Teres Minor – lateral rotation of arm Radial Nerve –Why is the Triceps spared?

33 Triceps, long head Triceps, lateral headTriceps, med hd Brachioradialis ECRL ECRBSuperficial SupinatorRadial sens Ext Digit Abd Pol LongusPost Interosseous Ext Pol Longus Ext Pol Br Ext Indicies

34 Sensory loss in a high radial nerve lesion (Signficant variability b/w patients)

35 Final Diagnosis Bilateral radial nerve palsies at the spiral (radial) groove related to fractures

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37 Case 3 A 25 year old man gets involved in a fist fight and the police arrest him When he is released on bail, he goes to see his doctor because he has numbness in the hand On exam he had –a number of scratches and bruises on both arms –normal strength –sensory loss on the dorsum of the hand

38 Patient’s sensory loss

39 Case 3, cont FindingPNPLEXUSRoot Sens LossSup Sens ---

40 Triceps, long head Triceps, lateral headTriceps, med hd Brachioradialis ECRL ECRBSuperficial SupinatorRadial sens Ext Digit Abd Pol LongusPost Interosseous Ext Pol Longus Ext Pol Br Ext Indicies

41 Final Diagnosis Superficial radial neuropathy secondary to handcuffs

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43 Case 4 15 yo football player is hit be another player, with the helmet striking him in the axilla On getting up, he is aware of shoulder weakness and pain and is taken to the ER

44 Case 4, cont On exam he has: –Normal elbow flexion –Normal elbow extension –Normal shoulder adduction –Ability to initiate shoulder abduction, but he cannot raise his arm more than 15 degrees –Mild weakness of external (lateral) rotation of the arm –A patch of sensory loss over his upper arm

45 Case 4, sensory loss

46 Case 4, cont FindingMusclePNPlexusRoot Abd>15DeltoidAxillaryPost C C5,6 Ext RotT. Minor Axillary Post C C5,6 Infrasp Suprascap UT C5,6 Sens Axillary ---

47 Case 4, continued FindingMusclePNPlexusRoot Abd>15DeltoidAxillaryPost C C5,6 Ext RotT. Minor Axillary Post C C5,6 Infrasp Suprascap C5,6 Sens Axillary ---

48 Case 4, cont If it’s at the posterior cord –Radial innervated muscles should be affected But elbow extension is spared If it’s C5,6 –Other C5,6 muscles should be affected But elbow flexion, initiation of arm abduction spared Pattern of sensory loss

49 Case 4, Final diagnosis Axillary Neuropathy

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51 Case 5 A 55 yo hospital worker comes to see you with a 2 week history of pain in her neck, which radiates into her shoulder, and upper arm Symptoms began when she tried to help restrain a combative patient

52 Case 5, cont On exam she she: –Weakness of shoulder abduction –Weakness of elbow flexion –Mild weakness of pronation –Sensory loss in her lateral forearm and thumb both posteriorly and anteriorly

53 Case 5, continued FindingMusclePNPlexusRoot Arm AbdDeltoidAxillaryPCC5,6 Elb FlexBC, BrachMuscLCC5,6 BRRadialPCC5,6 PronationPTMedianM & LCC6,7 Sens C6

54 FindingMusclePNPlexusRoot Arm AbdDeltoidAxillaryPCC5,6 Elb FlexBC, BrachMuscLCC5,6 BRRadialPCC5,6 PronationPTMedianM & LCC6,7 Sens C6

55 Case 5, Final Diagnosis C6 Radiculopathy secondary to a herniated disc

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57 Case 6 40 yo woman comes to see you because she has noticed weakness and numbness in her right hand This started 2 months ago and is slowly worsening She is otherwise healthy, and rides her bike at lease 40 miles per week

58 Case 6, continued On exam she has: –Atrophy of the interosseous muscles of the right hand –Mild weakness of abducting and adducting the fingers –Normal thumb abduction, opposition and extension –Normal wrist flexion in both a radial and ulnar direction

59 Sensory Loss

60 Case 6 continued FindingMusclePNPlexusRoot Fing AddPalm IntUlnarMCC8,T1 Fing AbdDors IntUlnarMCC8T1 Sens Loss----Ulnar---

61 Case 6 continued FindingMusclePNPlexusRoot Fing AddPalm IntUlnarMCC8,T1 Fing AbdDors IntUlnarMCC8T1 Sens Loss----UlnarMC

62 Case 6 continued If it’s the C8 nerve root, or medial cord –other muscles affected should include: APB and Opponens pollicus (median) EPL and EPB (radial) But these muscles are spare –more extensive sensory changes should be found

63 Ulnar nerve lesion Why is wrist flexion spared? Why does the sensory loss not include more of the dorsum of the hand?

64 Ulnar sensory loss in an ulnar lesion proximal to the midforearm

65 Ulnar nerve Elbow Flexor carpi ulnaris Flex Dig Prof III/IV Dorsal uln cut Wrist Adductor PollicusAbductor Flex Pollicus BrOpponens Digiti Minimi Flexor Dorsal/palmar Interosseous 3rd/4th lumbricals

66 Case 5, final diagnosis Ulnar neuropathy at the wrist

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68 Case 7 This 38 yo man fell off a ladder and acutely noted weakness in his right arm He suffered a fracture of his right clavicle He c/o pain in the shoulder

69 Case 7, cont His exam shows: –Weakness of initiating abduction of his right arm –If you raise his right arm to 90 degrees, he is unable to maintain it –With his arm at his side, he is unable to externally rotate his arm –Weakess of elbow flexion –Numbness of the lateral arm and forearm

70 Case 7, cont FindingMuscle RootPlexus Nerve 1 sh abdSupraspinatus C5,6UT Suprascap 2 sh abdDeltoid C5,6 UT Axillary Post Cord Ext rotInfraspinatus C5,6 UT Suprascap Teres minor C5,6 UT, PC Axillary Elbow flexion Biceps C5,6UT, LC Musc BR C5,6 UT, PC Radial Sensory C5 & 6 UT Axillary & LC & PC Musc

71 Case 7, cont FindingMuscle RootPlexus Nerve 1 sh abdSupraspinatus C5,6UT Suprascap 2 sh abdDeltoid C5,6 UT Axillary Post Cord Ext rotInfraspinatus C5,6 UT Suprascap Teres minor C5,6 UT, PC Axillary Elbow flexion Biceps C5,6UT, LC Musc BR C5,6 UT, PC Radial Sensory C5 & 6 UT Axillary & LC & PC Musc

72 Case 7, cont Difficult to distinguish based on exam alone if this is upper trunk or C5 and C6 radiculopathies –Brachial plexopathies may occur with fractures of the clavicle –Radiculopathies are unusual without neck pain –Preservation of the function of serratus anterior muscle makes root less likely –Further studies (EMG) can help localize b/w root and trunk

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74 Case 7, cont Final diagnosis: Upper trunk plexopathy

75 Don’t Forget to Vote!


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